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<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
<title>Hospital</title>
</head>
<body>
	<form action="">
		<table>
			<tr>
				<td>Hospital</td>
				<td>
					<select id="HospitalType" name="HospitalType">
						<option value="" label="Please Select..."/>
						<option value="Maharat ChiangMai Hospital" label="Maharat ChiangMai Hospital"/>
						<option value="PRIVATE" label="Bangkok Hospital"/>
					</select>
				</td>
			</tr>
			<tr>
				<td>Department of Hospital Name (THAI)</td>
				<td><input type="text" id="HospitalNameTH" name="HospitalNameTH"></td>
			</tr>
			<tr>
				<td>Department of Hospital Name (ENGLISH)</td>
				<td><input type="text" id="HospitalNameEN" name="HospitalNameEN"></td>
			</tr>
			<tr>
				<td>Bed Capacity Minimum</td>
				<td><input type="text" id="HospitalNameEN" name="HospitalNameEN"></td>
			</tr>
			<tr>
				<td>Bed Capacity Maximum</td>
				<td><input type="text" id="HospitalNameEN" name="HospitalNameEN"></td>
			</tr>
			<tr>
				<td colspan="2" align="center">Director</td>
			</tr>
			<tr>
				<td>Title</td>
				<td><input type="text" id="DirectorTitle" name="DirectorTitle"></td>
			</tr>
			<tr>
				<td>First Name</td>
				<td><input type="text" id="DirectorFirstName" name="DirectorFirstName"></td>
			</tr>
			<tr>
				<td>Last Name</td>
				<td><input type="text" id="DirectorLastName" name="DirectorLastName"></td>
			</tr>
			<tr>
				<td>Telephone</td>
				<td><input type="text" id="DirectorTelephone" name="DirectorTelephone"></td>
			</tr>
			<tr>
				<td>E-Mail</td>
				<td><input type="text" id="DirectorEmail" name="DirectorEmail"></td>
			</tr>
			<tr>
				<td>Rating of IMP</td>
				<td>
					<div id="div_imp_rate_director">
						<input type="radio" name="imp_rate_director" id="imp_rate_director0" value="0" checked="checked"><label for="srh_imp_rate_president0">none</label>
						<input type="radio" name="imp_rate_director" id="imp_rate_director1" value="1"><label for="srh_imp_rate_president1">1</label>
						<input type="radio" name="imp_rate_director" id="imp_rate_director2" value="2"><label for="srh_imp_rate_president2">2</label>
						<input type="radio" name="imp_rate_director" id="imp_rate_director3" value="3"><label for="srh_imp_rate_president3">3</label>
						<input type="radio" name="imp_rate_director" id="imp_rate_director4" value="4"><label for="srh_imp_rate_president4">4</label>
						<input type="radio" name="imp_rate_director" id="imp_rate_director5" value="5"><label for="srh_imp_rate_president5">5</label>
					</div>
				</td>
			</tr>
			<tr>
				<td>Rating of RP</td>
				<td>
					<div id="div_rp_rate_president">
						<input type="radio" name="rp_rate_president" id="rp_rate_president0" value="0" checked="checked"><label for="srh_rp_rate_president0">none</label>
						<input type="radio" name="rp_rate_president" id="rp_rate_president1" value="1"><label for="srh_rp_rate_president1">1</label>
						<input type="radio" name="rp_rate_president" id="rp_rate_president2" value="2"><label for="srh_rp_rate_president2">2</label>
						<input type="radio" name="rp_rate_president" id="rp_rate_president3" value="3"><label for="srh_rp_rate_president3">3</label>
						<input type="radio" name="rp_rate_president" id="rp_rate_president4" value="4"><label for="srh_rp_rate_president4">4</label>
						<input type="radio" name="rp_rate_president" id="rp_rate_president5" value="5"><label for="srh_rp_rate_president5">5</label>
					</div>
				</td>
			</tr>
			<tr>
				<td>Remark</td>
				<td>
					<textarea name="remark" id="remark" rows="5" cols="20" title="Please Input"></textarea>
				</td>
			</tr>				
		</table>
	</form>
</body>
</html>